case study of depression in pakistan

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Social and Cultural Pressures and Depression in Pakistani Women: A Case Report

Saleha Bibi 1* , Urwah Ali 2

Copyright : © 2018 Authors. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

This study shows a case of young girl of 19 years of age. She was brought Fouji Foundation hospital with the symptoms of loss of appetite, dry mouth, insomnia, suicidal thoughts, loss of pleasures, feeling of guilt and low self esteem. Diagnoses was made according to DSM -5. Through detail investigation it was known that her symptoms were not due to any biological cause rather they were due poor social condition and cultural pressures in which she living. Psychotherapies including cognitive behaviour therapy, interpersonal and couple therapy were applied in this case. The patient showe d significant improvement in her condition.

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Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review

  • Related content
  • Peer review
  • Ilyas Mirza ( ilyasmirza{at}blueyonder.co.uk ) , specialist registrar in adult psychiatry 1 ,
  • Rachel Jenkins , visiting professor and director 2
  • 1 Royal London Hospital (St Clement's), London E3 4LL
  • 2 WHO Collaborating Centre for Mental Health, Institute of Psychiatry, London SE5 8AF
  • Correspondence to: I Mirza, Larkswood Centre, Thorpe Coombe Hospital, London E17 3HP
  • Accepted 5 March 2004

Objectives To assess the available evidence on the prevalence, aetiology, treatment, and prevention of anxiety and depressive disorders in Pakistan.

Design Systematic review of published literature.

Studies reviewed 20 studies, of which 17 gave prevalence estimates and 11 discussed risk factors.

Main outcome measures Prevalence of anxiety and depressive disorders, risk factors, effects of treatment.

Results Factors positively associated with anxiety and depressive disorders were female sex, middle age, low level of education, financial difficulty, being a housewife, and relationship problems. Arguments with husbands and relational problems with in-laws were positively associated in 3/11 studies. Those who had close confiding relationships were less likely to have anxiety and depressive disorders. Mean overall prevalence of anxiety and depressive disorders in the community population was 34% (range 29-66% for women and 10-33% for men). There were no rigorously controlled trials of treatments for these disorders.

Conclusions Available evidence suggests a major social cause for anxiety and depressive disorders in Pakistan. This evidence is limited because of methodological problems, so caution must be exercised in generalising this to the whole of the population of Pakistan.

Introduction

Anxiety and depressive disorders are common in all regions of the world. 1 They constitute a substantial proportion of the global burden of disease, and are projected to form the second most common cause of disability by 2020. 2 This increased importance of non-communicable diseases such as anxiety and depressive disorders presents a particular challenge for low income countries, where infectious diseases and malnutrition are still rife and where only a low percentage of gross domestic product is allocated to health services. 3 These disorders are also important because of their economic consequences. 4

With an estimated population of 152 million, Pakistan is the sixth most populous country in the world. It is projected that, by 2050, the population will have increased to make it the fourth most populous country. 5 There is a need to develop an evidence base to aid policy development on tackling anxiety and depressive disorders. We therefore conducted a systematic review as no such work existed to our knowledge.

Our main questions were ( a ) what the estimated prevalence of anxiety and depressive disorders is in Pakistan and how this compares with estimates from other low income countries; ( b ) what the associated social, psychological, and biological factors are; and ( c ) what evidence exists for effectiveness of treatment or prevention in this population.

Data sources

Using the key words “Pakistan” and (“mental” or “depression” or “anxiety” or “psychiatric”), we searched the following bibliographic databases from the start of each of their time frames: Applied Social Sciences Index and Abstracts, Cumulative Index to Nursing and Allied Health, Cochrane Trials Register, Excerpta Medica, National Library of Medicine Gateway, Medline (Pubmed), PsycINFO, Science Citation Index, and Social Science Citation Index. We searched the reference lists of retrieved articles for relevant studies. We also searched www.Pakmedinet.com , a medical website. These searches were last repeated on 1 March 2002 to keep the review as current as possible. Additionally, we hand searched the Pakistan Journal of Clinical Psychiatry until 1995, when it ceased publication.

Study selection

We selected studies that were conducted within Pakistan and that focused on depression, depressive disorder, or anxiety disorder in adults (ages 18-65). Variables of interest were prevalence, vulnerability factors, protective factors, and effectiveness of treatment and prevention strategies.

Data extraction

Each study received a code based on the relevance of its abstract and title to the study questions. Studies or reviews directly addressing anxiety and depressive disorders were retrieved for data extraction. Potentially useful qualitative and quantitative studies, as well as review articles were also retrieved. (A complete list is available from the authors.)

Validity check

We assessed the methodological quality of the selected studies according to hierarchies of evidence and critical appraisal checklists. 6 Since relatively few studies addressed our study questions, we included all studies directly relevant to the questions regardless of their quality.

Study synthesis

A narrative synthesis of the extracted studies was performed to address the questions of the review.

We found 20 studies that directly addressed the questions of the review: 19 were cross sectional epidemiological surveys, and one was a case-control study. w1-w20 Seventeen gave prevalence estimates (n = 9170), while 11 discussed associated risk factors. We did not find any prospective study of the natural course of the disorder or a rigorously controlled study of any interventions. We found little qualitative work. Sample sizes ranged from 113 to 2620 in prevalence studies (mean 539.41, median 298).

Methods of included studies

Table 1 shows the methodological quality of the studies. Only three of the 11 prevalence studies published in local journals gave adequate details of methods. Because of this, it is difficult to comment on possible biases. Even when basic data were provided it is questionable how representative the study sample was of the population. 7 Diagnoses in all the studies were made by either a psychiatrist or a trained worker using a validated instrument, and thus seem to be of reasonably good quality.

Checklist for quality of studies included in systematic review of evidence on prevalence, aetiology, treatment, and prevention of anxiety and depressive disorders in Pakistan

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Most of the studies discussed the generalisability of their findings but did not interpret any null findings. In the discussions, national comparisons were rarely made with findings of other national research groups; comparisons were usually with studies in other countries.

Prevalence of anxiety and depressive disorders

Table 2 lists the prevalence of anxiety and depressive disorders estimated in the studies. The overall mean prevalence in men and women in the six studies of random community samples (n = 2658) was 33.62%, with the point prevalence varying from 28.8% to 66% for women (overall mean 45.5%) and from 10% to 33% for men (overall mean 21.7%). Women aged 15-49 were studied in a paper with 28.8% prevalence, while young men with a mean age of 18 participated in a study reporting 33% prevalence. Only one study reported adjusted prevalence with 95% confidence intervals.

Details of studies included in systematic review with prevalence estimates of anxiety and depressive disorders

For those presenting to traditional or faith healers (n = 511), the prevalence of anxiety and depressive disorders among men varied from 2.65% to 27%, and among women from 11.5 % to 52%.

Three studies looked at total psychiatric morbidity in primary care (n = 774). One described women in a rural area, with a prevalence of 50%, while another described 18% prevalence for men and 42.2% for women in an urban area. The third study, with a prevalence of 38.4%, did not specify participants' sex.

Of those presenting to psychiatric outpatients (n = 2430), the prevalence varied between 32% and 66.3%. There were two studies on psychiatric inpatients, one reported a prevalence of depressive illness of 37% (n = 2620), while the other reported 19.1% (n = 177).

Associated social, psychological, and biological factors

Table 3 shows the various factors found to be associated with anxiety and depressive disorders. Sociodemographic factors associated with increased prevalence of anxiety and depressive disorders were female sex, middle age, and low level of education. Loss of husband (being widowed, separated, or divorced), increasing duration of marriage, and being a housewife were also positively associated. Women living in joint households with more than 12 members also showed a positive association; in contrast, one study reported a positive association for women living in unitary households. One study showed a positive significant association for relational problems with in-laws for women compared with other social problems. Chronic difficulties with housing, finances, and health were significantly associated with anxiety and depressive disorders. Absence of a confiding relationship was a significant factor in one study, as were lack of autonomy and arguments with husbands and in-laws in another. A disturbing event in the family was not significantly associated (P = 0.08).

Factors associated with risk of anxiety and depressive disorders in studies included in systematic review

Factors perceived by women to be associated with mental distress were low family income, marital disputes, too many children, and verbal abuse by in-laws. Studies that incorporated income found financial difficulties to be a significant factor, except for one study, in which the finding was just non-significant (P = 0.06).

What is the evidence for effectiveness of treatment or prevention in this population?

We could not find any prospective study of the natural course of the disorder or any rigorous controlled study addressing effectiveness of treatment and prevention. We found only one randomised controlled trial in mental health, regarding the ability of schoolchildren to detect mental disorders after having been given health education. 8

In our systematic review we found that socioeconomic adversity and relationship problems were major risk factors for anxiety and depressive disorders in Pakistan, whereas supportive family and friends may protect against development of these disorders.

Limitations of study

Our review may be subject to publication and selection bias as we were unable to systematically contact the experts in Pakistan for unpublished material or grey literature.

The coverage of the studies we identified is low. Despite detailed searches, we found that most studies satisfying our inclusion criteria were from the provinces of Punjab and Sindh, the two provinces with the largest population in Pakistan. The epidemiological data were collected from a handful of villages and urban settlements. There was considerable methodological variation in study design and in the instruments used. Thus one is unable to extrapolate these epidemiological findings to the whole of Pakistan.

Comparison with other low income countries

Using stringent criteria, Harding et al reported an overall frequency of anxiety and depression of 13.9% in four developing countries. 9 Community studies from Africa have reported prevalences of 24% in rural Uganda and 20%-24% in rural South Africa. Among patients attending primary care, the prevalence varied from 8% to 29%. Patients attending primary care in India showed prevalences between 21% and 57%. 1

In relation to risk factors, Abas and Broadhead found a significant association with formal employment, below average income, overcrowding, and certificate of secondary education in urban Zimbabwe. 10 In the same study, they also found a significant association with humiliation or entrapment and with death or other loss. 11 Bhagwanjee in rural South Africa found a significant association with age (risk increasing with age, to a maximum among people aged 30-39 years), single marital status, unemployment, low income, and low educational level. 12 Similar risk factors were found in studies from Pakistan. However, we found that the reported overall rates were higher in Pakistan and higher among rural than urban populations compared with the above studies. The question is whether these differences are an artefact of measurement or are because of specific factors operating in Pakistan.

Possible reasons for our findings

Pakistan's population has been exposed to sociopolitical instability, economic uncertainty, violence, regional conflict, and dislocation for at least the past three decades. 13 These are risk factors for psychiatric disorders 3 and may help explain the findings of this review.

As in many other countries, women in Pakistan generally have higher rates of illness than men. In a recent study, the main health problems reported by women were mental tension leading to headache and white vaginal discharge leading to body pains and fatigue. 14 In another study, most women perceived that financial, interpersonal, and family problems were causative or contributory factors in their ill health. They also linked their health to broader social institutions and cultural norms and expectations regarding women's roles and relationships between family members. 15

The need for stronger evidence and improved research capacity

The argument that health will automatically improve with economic growth is not supported by the current evidence. Diseases will not go away without specific investments in health interventions. 3 A coherent mental health policy with a strategic implementation plan is essential for countries that wish to enhance their social, economic, and social capital. 16

A major obstacle in formulating effective health policy is the lack of robust epidemiological research in Pakistan. 17 Our review highlights the absence of survey evidence and data from wider regions of Pakistan with regard to anxiety and depression, and the lack of outcome studies and prevention and treatment trials. The time is right for Pakistan to build on this research effort by increasing investment in research capacity. It would also be helpful to have a national epidemiological survey of mental disorders. Such surveys are useful to assess the needs of the population, document the use of existing services, obtain valid information on prevalence and associated risk factors, and monitor the health of the population and trends. 16

Available evidence suggests a major social cause for anxiety and depressive disorders in Pakistan, and an overall prevalence of 34%. This evidence is limited because of methodological problems. Nationally representative psychiatric morbidity surveys and controlled treatment trials are required to inform policy in order to control morbidity from anxiety and depressive disorders.

What is already known on this subject

Anxiety and depressive disorders are associated with considerable economic burden

These disorders represent an emerging public health threat in low income countries

What this study adds

In Pakistan relationship problems, financial difficulties, and low educational level are positively associated with anxiety and depressive disorders, whereas having a supportive relationship is negatively associated

Systematically collected, peer reviewed evidence suggests an overall prevalence of 34% for anxiety and depressive disorders in this population, but this finding must be treated with caution because of methodological limitations

Nationally representative psychiatric morbidity surveys and controlled treatment trials are needed to inform policy in order to control morbidity from anxiety and depressive disorders in Pakistan

Funding None.

Competing interests None declared.

Ethical approval Not required.

Contributors IM proposed the idea, which was further developed by RJ. IM performed the literature search and data extraction. IM and RJ both wrote the paper. IM is guarantor for the study.

  • Institute of Medicine
  • World Health Organization
  • Desjarlis R ,
  • Eisenberg L ,
  • Population Division, Department of Economic and Social Affairs, United Nations Secretariat. U.N.
  • Greenhalgh T
  • Mubbashar M ,
  • Harding TW ,
  • de Arango MV ,
  • Baltazar J ,
  • Climent CE ,
  • Ibrahim HH ,
  • Ladrido-Ignacio L ,
  • Broadhead J
  • Broadhead J ,
  • Bhagwanjee A ,
  • Petersen I ,
  • Winkvist A ,

case study of depression in pakistan

Prevalence of depression and anxiety among general population in Pakistan during COVID-19 lockdown: An online-survey

Affiliations.

  • 1 Kabir Medical College, Gandhara University, Peshawar, Pakistan.
  • 2 Ziauddin Medical University, Karachi, Pakistan.
  • 3 Department of Humanities, COMSATS University, Lahore, Pakistan.
  • 4 Paraplegic Centre, Hayatabad, Peshawar, Pakistan.
  • 5 Department of Medicine, Northwest general hospital and Research Centre, Peshawar, Pakistan.
  • 6 Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8 Canada.
  • 7 Center for Transdisciplinary Research, SIMATS, Saveetha University, Chennai, India.
  • 8 Department of Community Medicine, Faculty of Medicine, Datta Meghe Institute of Medical Sciences, Wardha, India.
  • 9 Department of Nursing, School of Health and Welfare, Jönköping University, Gjuterigatan 5, 553 18 Jönköping, Sweden.
  • PMID: 35194356
  • PMCID: PMC8830029
  • DOI: 10.1007/s12144-022-02815-7

The present study's aim is to find the prevalence of two of the common indicators of mental health - depression and anxiety - and any correlation with socio-demographic indicators in the Pakistani population during the lockdown from 5 May to 25 July 2020. A cross-sectional survey was conducted using an online questionnaire sent to volunteer participants. A total of 1047 participants over 18 were recruited through convenience sampling. The survey targeted depression and anxiety levels, which were measured using a 14 item self-reporting Hospital Anxiety and Depression Scale (HADS). Out of the total sample population ( N =354), 39.9% suffered from depression and 57.7% from anxiety. Binary logistical regressions indicated significant predictive associations of gender ( OR=1.410 ), education ( OR=9.311 ), residence ( OR=0.370 ), household income ( OR=0.579 ), previous psychiatric problems ( OR=1.671 ), and previous psychiatric medication (OR=2.641) . These were the key factors e associated with a significant increase in depression. Increases in anxiety levels were significantly linked to gender ( OR=2.427 ), residence ( OR=0.619 ), previous psychiatric problems ( OR=1.166 ), and previous psychiatric medication ( OR=7.330 ). These results suggest depression and anxiety were prevalent among the Pakistani population during the lockdown. Along with other measures to contain the spread of COVID-19, citizens' mental health needs the Pakistani government's urgent attention as well as that of mental health experts. Further large-scale, such as healthcare practitioners, should be undertaken to identify other mental health indicators that need to be monitored.

Keywords: Anxiety; COVID-19; Cross-sectional design; Depression; Gender; General population; Mental health.

© The Author(s) 2022.

SYSTEMATIC REVIEW article

Prevalence of depressive symptoms among university students in pakistan: a systematic review and meta-analysis.

\nMuhammad Naeem Khan,

  • 1 Metro South Addiction and Mental Health Services, Brisbane, QLD, Australia
  • 2 School of Medical Sciences, Griffith Health, Griffith University, Brisbane, QLD, Australia
  • 3 School of Public Health, Global Health Institute, Xi'an Jiaotong University, Xi'an, China
  • 4 Department of Psychiatry, King Edward Medical University, Lahore, Pakistan
  • 5 Institute of Population Health, University of Liverpool, Liverpool, United Kingdom
  • 6 Human Development Research Foundation (HDRF), Islamabad, Pakistan

Background: In Pakistan, almost 30% population is between 15 to 29 years of age, with university enrollment rates of 10–15%. Although there is a growing concern on mental health of university students across the globe, studies from low and middle income countries such as Pakistan are scarce. We conducted a systematic review and meta-analysis of prevalence of depressive symptoms among Pakistani university students.

Methods: PubMed, Web of Science, PsycInfo and Google Scholar were searched between 15 to 30th January 2020. Cross-sectional and longitudinal studies, published till 31st December 2019 were included. Data on study characteristics and prevalence of depressive symptoms were extracted. Meta-analysis was conducted using random effects models. To estimate subgroup difference based on study characteristics, meta-regression and sub-group analyses were conducted.

Results: In total, 26 studies involving 7,652 participants were included in review. Overall prevalence of depressive symptoms was 42.66% (95% CI: 34.82% to 50.89%), with significant heterogeneity among studies. Subgroup analyses revealed a significant difference in prevalence estimates based on depression screening instrument and study major. Statistically significant differences were observed among studies employing different psychometric scales (test for subgroup differences, Q = 21.92, p < 0.05) and between students from different study majors (test for subgroup differences, Q = 3.76, p = 0.05).

Conclusion: Our study found that overall prevalence of depressive symptoms among university students in Pakistan was 42.66%, however, findings should be interpreted with caution. Large scale epidemiological surveys using valid and reliable tools are needed to better estimate prevalence of depression among Pakistani university students.

Introduction

Depressive disorders are leading cause of disability worldwide ( 1 , 2 ). Studies suggest that most Common Mental Disorders (CMDs) have their first onset before the age of 24 ( 3 ). Anxiety and mood disorders are highly prevalent among young people aged 18–29 years. Almost 40% of young people experience their first episode of depression before the age of 20, with an average age of onset in the mid-20s ( 4 ). These years are most important for education, employment and social relationships.

Over the last decade, there has been growing interest in the mental health of university students. Globally, 24 to 34% university students experience depressive symptoms ( 5 – 9 ). Depressive disorders are one of the major causes of years lost due to disability (YLDs) and Disability Adjusted Life Years (DALYs) in young people ( 10 ). Occurrence of depression during the critical period of transition from adolescence to adulthood may have adverse effects, not only on development and academic functioning, but also on future employment and work productivity. Studies have shown that depression leads to early attrition from university and poor academic performance ( 11 – 13 ). Moreover, depression is associated with lower employment prospects and unstable employment in adulthood ( 14 ).

Pakistan-a Context

Pakistan is one of the youngest countries in the region, with almost 30% population between 15 to 29 years of age ( 15 ). In addition to having limited resources to invest in education and health, Pakistan has witnessed some major crises over the last two decades. The country was hit by a major earthquake in 2005 and heavy floods in 2010. A long wave of terrorism and militancy (2000–2014) did not even spare schools and colleges. More than 100 children were dead in a terrorists attack on Army public school Peshawar in 2014-the highest death tool in a single terrorist attack in the world. In 2016, a university in north-west province was attacked by terrorists, resulting in deaths of 19 students and teachers.

In Pakistan, a whole generation has grown up in an uncertain and insecure environment. Almost 70% population lives in rural areas. Meanwhile, over the last 20 years, trend of enrollment in higher education institutes has increased substantially with 10–15% of the eligible age group of 18–24 in universities or professional colleges ( 16 , 17 ). Even from less privileged areas, young people are getting higher education. Most of these people are form the first generation of their families to receive higher education.

With almost non-existent career counseling and mental health services at campuses, university students in Pakistan battle with a highly competitive environment, financial constraints, future uncertainty and parental and societal demands to excel in studies and secure good jobs. All these stressors put university students at high risk of developing common mental health problems particularly depression. For a developing country like Pakistan, health and well-being of its youth is of utmost importance as they are the future human capital.

There is a need for reliable estimates of prevalence of mental health problems among university students to design interventions tailored to specific needs of youth in Pakistan. Present study aims to conduct systematic review and meta-analysis on prevalence of depression among university students in Pakistan.

Study Design

This systematic review and meta-analysis was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ( 18 ). A complete PRISMA Checklist is available as Supplementary Table 2 .

Participants, Intervention Comparators

Eligibility Criteria were defined according to the PICO ( 18 ).

Population - University students of any age.

Intervention/Exposure - Depression/depressive symptoms.

Intervention - not required for inclusion.

Comparison - not required for inclusion.

We included cross-sectional or longitudinal studies (baseline data) reporting prevalence of depressive symptoms among university students in Pakistan.

Exclusion criteria were studies reporting other study designs such as Randomized Controlled Trials (RCTs), case control studies, reviews (narrative and systematic), conference proceedings, case reports, qualitative studies, editorials, opinion papers, and letters. In addition, we did not include unpublished or non-peer reviewed articles.

Systematic Review Protocol

Protocol for this systematic review is registered in International prospective register of systematic reviews (PROSPERO) under registration number CRD42020170099.

Literature Search Strategy and Data Sources

We systematically searched PubMed, Web of Science, PsycInfo and Google scholar databases from January 15 th to 30 th 2020 for studies reporting primary data on depressive symptoms among university students in Pakistan, published till December 2019. In addition, the authors screened the reference lists of identified articles using the approaches implied by the Preferred Reporting Items for Systematic Reviews and Meta-analyses ( 18 ). For the database searches, a pre-tested search strategy, combining terms related to university students and depression was employed. To avoid irrelevant results, search was restricted to only English language studies as no research studies are published in local/national language of Pakistan (Complete details of the search strategy appear in Supplementary Table 1 ).

Studies Selection and Data Extraction

The database searches were conducted by one author (MNK). After deletion of duplicate records using Endnote software, two authors (PA and MNK) independently screened all the titles and abstracts against the eligibility criteria. Any disagreements regarding inclusion for full-text screening were resolved through discussion with a third reviewer (SI). Thereafter, two authors (PA and MNK) independently reviewed the full-texts of all included articles. Disagreements were discussed with third author (SI) to achieve consensus. One author (PA) extracted data from all the included articles while 2nd author (MNK) extracted data from 25% of the studies to ensure accuracy and completeness of data extraction. Before starting the data extraction, both authors extracted data from three articles independently to establish inter-rater reliability. We found good inter-rater reliability between the two reviewers (k = 0.85).

Using a standardized data extraction sheet, data on following characteristics of included studies was extracted: author and publication years, study design, mean age of sample (or range, where mean was not available), sample size, sampling technique, number and percentage of females in the sample, education level, study major, instrument used to screen for depression, screening instrument cutoff, number of females with depression and overall prevalence of depressive symptoms.

Risk of Bias

Risk of bias in the included studies was assessed using a modified version of the Joanna Briggs Institute (JBI) critical appraisal checklist for prevalence studies ( 19 ). JBI is frequently used quality assessment tool for prevalence studies ( 20 – 22 ). This checklist assesses each study on 9 items including sample representativeness, recruitment appropriateness, adequate sample size, description of subjects and setting, valid ascertainment and measurement of the condition, thoroughness of reporting statistical analysis, standard measurement for all participants and adequacy of response rate. We modified Item 5 (original item “Was data analysis conducted with sufficient coverage of the identified sample” changed to “was scale valid/reliable in Pakistani context). Studies were categorized to be at low risk of bias (≥7 points), moderate risk of bias (4–6 points) or high risk of bias (<4 points). The quality assessment did not determine inclusion/exclusion of the study in meta-analysis.

Data Analysis

Descriptive statistics pertaining to prevalence of depressive symptoms and its overall severity were extracted. Studies were assessed based on methodological and statistical heterogeneity. Due to significant heterogeneity, data was pooled using random effects model and forest plots were generated displaying pooled prevalence with 95% confidence intervals. Between-study heterogeneity was assessed using standard χ 2 tests, Tau 2 and the I 2 statistics ( 23 , 24 ). I 2 was presented as the percentage of variability in prevalence estimates due to heterogeneity rather than sampling error, or chance, with values ≥75% indicating considerable heterogeneity ( 23 , 24 ). Sensitivity analysis using single study “knock out” approach was used to determine influence of each study on the pooled prevalence.

Publication bias was assessed by visual inspection of the funnel plot and Egger's tests (considered significant at p < 0.1). ( 25 , 26 ). Duval and Tweedie's trim and fill method was used to adjust pooled prevalence estimate for publication bias ( 27 ). To explore heterogeneity among studies, we conducted subgroup analyses for categorical moderators, and meta-regression for continuous variables. Subgroups were conducted by field of study, level of education, university type (public /private), depression screening tool, sampling technique and study quality. All subgroup analyses were conducted using the mixed-effect method where a p -value of 0.05 was considered as having statistically significant subgroup differences.

Meta regression with maximum likelihood method and random effects was conducted to determine effect of age, sample size and percentage of females in the sample on the pooled prevalence. To ensure appropriate statistical power, we conducted subgroup analysis when subgroups were reported in at least four studies ( 28 ). While meta-regression analysis were run for moderators reported in at least ten studies ( 29 ). All the analysis were conducted in Comprehensive Meta-analysis software (CMA) version 3 ( 30 ). All statistical tests were 2-sided and p -values < 0.05 was considered statistically significant.

Study Selection Process

Our databases search yielded 137 records. After removal of 32 duplicates, 105 studies were screened for titles and abstracts against inclusion and exclusion criteria. After the screening process, a total of 45 full texts were found eligible for further assessment. We excluded 19 studies as the studies did not report prevalence of depression. A total of 26 full-texts were included in both the qualitative and quantitative synthesis. A detailed flow chart of the search and selection process is presented in Figure 1 .

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Figure 1 . PRISMA flow diagram.

Characteristics of Included Studies

Table 1 summarizes the basic characteristics of included studies. In total, 26 studies involving 7,652 participants were included in the analysis. The median number of participants per study was 289 (range, 66–1000). No longitudinal study was identified and all the included studies in our review were cross-sectional studies. Majority of the studies (24/26, 92%), were conducted with undergraduate students and only two studies included both undergraduate and graduate students. More than half (17/26, 65%) studies included only medical students. Among the studies conducted with students from non-medical majors, studies did not explicitly mentioned the study discipline. 10 (38.50%) studies recruited sample from public universities, 6 from private universities, 5 studies included mix sample from both, private and public universities, and 5 studies did not specify university type. Most of the studies used self-reporting screening tools to assess depression; 4 studies (15%) used Hospital Anxiety and Depression Scale (HADS), 3 studies (11.54%) used Beck Depression Inventory (BDI), 4 studies (15%) used Depression Anxiety Stress Scale-21 (DASS-21), 3 studies (11.54%) used Depression Anxiety Stress Scale-42 (DASS-42), Beck Depression Inventory-II (BDI-II), Center for Epidemiological Studies Scale for Depression (CESD) and Zungs Self-report Depression Scale (Zung-SDS) were used in two studies each. One study each used Quick Inventory for Depression Screen (QIDS), Patient Health Questionnaire-9 (PHQ-9), Duke Health Profile and Hamilton Depression Scale (HAM-D) while 3 studies did not specify the depression ascertainment methods.

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Table 1 . Characteristics of included studies.

Synthesized Findings

Prevalence of depression in university students in pakistan.

There was an evidence of substantial statistical heterogeneity among the included studies (I 2 = 97.68%, Cochran's Q = 1078.55, p < 0.001). Therefore, random effects were employed while pooling event rates across studies, yielding a pooled prevalence rate of 42.66% (95% CI: 34.82 to 50.89%) (see Figure 2 ). Out of 7,652 university students, a total of 3,549 reported having depressive symptoms according to different screening tools.

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Figure 2 . Meta-analysis of 26 studies on prevalence of depressive symptoms among university students in Pakistan.

Subgroup Analyses

Several subgroup analyses were conducted in this meta-analytical investigation. Prevalence of depression among undergraduate students ( n = 24) was slightly lower as compared to studies that included sample from both graduate and undergraduate levels ( n = 2). Among undergraduates students a prevalence rate of 42.24% (95%CI: 33.5-49.79%) of depressive symptoms was reported as compared to 48.86% (95% CI:2.88-96.85%) by other student population. Studies employing random sampling yielded lower prevalence rates (33.47%, 95% CI: 23.26-45.51%) than non-random counterparts (44.49%, 95% CI: 35.29-54.09%). Studies with lowest risk of bias reported the lowest prevalence rate of 30% (95% CI: 31.13-51.37%) than their counterparts with moderate (48.09%, 95% CI: 36.53-59.86%) and highest risk of bias (40.71%, 95% CI: 14.82-51.37%), however, none of these difference was statistically significant ( Table 2A ).

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Table 2A . Subgroup analysis based on study characteristics.

Students enrolled in disciplines other than medicine reported higher prevalence of depressive symptoms (53.59%, 95% CI: 40.71%-66%) as compared to medical students (36.90%, 95% CI: 27.14-47.86%). The difference was statistically significant (test for subgroup differences, Q = 3.76, p = 0.05). Lowest percentage of depressive symptoms were reported by private sector university students (26.13%; 95% CI: 14.37-42.71%) than those studying in public (government funded) universities (42.60%, 95% CI: 29.45-56.90) or studies which included sample from both public and private universities (45.94% 95%CI: 27.31-65.77%). However, this difference did not yield statistical significance (test for subgroup differences, Q = 3.13, p = 0.21) (see Table 2A ).

When comparing prevalence rates of depression between studies employing different psychometric scales, statistically significant differences were observed (test for subgroup differences, Q = 21.92, p < 0.05). There was evidence of significant variation in the extent of heterogeneity observed across studies employing different scales. Lowest prevalence of depressive symptoms was reported as per BDI-II scale and the highest according to CES-D and HAM-D scale (see Table 2B ).

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Table 2B . Subgroup analysis based on depression screening instrument.

Meta Regression Analysis

Meta-regression analyses using random effects model was conducted to analyze association between prevalence rates of depressive symptoms, age of sample, total sample size and proportion of females in the sample. Each variable accounted for only 3% of variance in heterogeneity in the reported effect size, and did not yield statistical significance ( p > 0.05). (see Tables 3A – C ).

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Table 3A . Meta-regression analysis for the prevalence (%) of depression in university students with proportion of females.

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Table 3B . Meta-Regression analysis for the prevalence (%) of depression in university students with mean age of sample.

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Table 3C . Meta-regression analysis for the prevalence (%) of depression in university students with sample size.

Sensitivity Analysis

Sensitivity analysis did not indicate any changes in the mean prevalence when individual studies were removed from the meta-analysis, except the removal of two studies ( 34 , 42 ) independently reduced the prevalence rate of depression from 42.7 to 40%. (See Supplementary Figure 1 ).

Assessments of Publication Bias

There was some evidence of publication bias in reporting of prevalence of depression among university students (Egger's statistic = −6.09 (3.44), p = 0.09).

Trim and fill method using random effects was used to adjust the pooled prevalence estimates for publication bias. After imputing one study to the right of mean, it yielded an adjusted prevalence of 40.45% among university students (95% CI: 31.21% to 50.42%) (see Figure 3 ).

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Figure 3 . Funnel plot for publication bias with trim and fill method.

Most of the included studies had a moderate to high risk of bias. Mean quality score was 5.12 (SD; 1.53) out of 9. Only 6 studies had low risk of bias, while 15 out of 26 (58%) studies had a moderate to high risk of bias. Out of 26 studies, 21 studies did not report or cite the reference of scale's psychometric properties for Pakistani population. Only 4 (15%) studies employed random sampling technique, and 11 (42%) studies included sample from multiple schools/universities. Response rate was given in 12 (46%) studies. Risk of bias score for all individual studies has been shown in Table 4 .

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Table 4 . Risk of bias in included studies.

Summary of Main Findings

In this systematic review and meta-analysis of 26 studies involving 7652 university students, prevalence of depressive symptoms was found to be 42.66% (95% CI: 34.8-50.9%). Overall prevalence is higher than the recent estimated prevalence rates of 24% (95% CI, 19.2%−30.5%) among university students in LMICs as reported by Akhtar et al. ( 9 ) as well as recent global estimates among medical students (27%, 95% CI, 24.7 to 29.9%) reported by Rotenstein et al. ( 7 ). This is alarming given relatively low university enrollments rates in low resource countries like Pakistan.

University environment in Pakistan is getting more and more competitive. University teachers, parents and society in general value high achievers. The constant pressure of getting good grades and landing a decent job may lead to feeling of stress and depression. There are no psychological and career counseling services at university campuses. Very few available metal health services are concentrated in tertiary healthcare facilities in big cities. In addition, lack of awareness and training among teachers to recognize and support students with common mental health problems and stigma attached to mental health problems are major barriers in seeking professional help. All these factors cause unnecessary delay in treatment, resulting in worsening the problems.

Prevalence of depression among students with non-medical majors was significantly higher than those with medical. Those enrolled in medicine reported lower prevalence of depression (36.90%, 95% CIs: 27.14-47.86%) than those in degree programs other than medicine (53.59%, 95% CI: 40.71-66%). In Pakistan, medicine and engineering are the first choice of most of students and their parents. However, securing admission in these fields is very competitive due to limited number of public medical and engineering colleges. Many students who cannot make to medical and engineering colleges, choose other fields. At one hand, they may feel less satisfied and not being able to fulfill the expectations of parents, and frustrated with highly competitive job market and limited career opportunities on the other hand. However, it should be noted that there were very few studies having sample from non-medical study majors in this review.

Significant difference in prevalence estimates was found in studies using different screening tools. Different tools employ different cut-offs and sometimes same tool can be used with different cut-offs. Moreover, most of studies did not mention the psychometric properties for Pakistan population. Previous studies also indicate a difference in prevalence estimates based on screening instruments ( 7 ).

Quality assessment of studies indicated few high quality studies. Only few studies employed random sampling techniques and recruited sample from multiple school, this could have introduce a selection bias in the individual studies included in this review, indicating scarcity of large scale, valid and reliable surveys.

Moreover, we found only 26 studies in four major databases, without publication dates restrictions. This is an indication of overall scarcity of research in this field in Pakistan

A high prevalence of depressive symptoms among Pakistani university students is a threat to healthy development of students and their smooth transition to adulthood. It may have long-term adverse effects for individuals as well the nation. Researchers and policy maker should focus this problem in future research. There is need for valid and reliable estimates prevalence of depressive symptoms among Pakistani university students, following guidelines for large epidemiological studies ( 57 ). Longitudinal studies are needed to analyze risk and protective factors for depression, with a focus on cultural factors. Barriers to access to mental health services need to be addressed by campus-based mental health services and community based interventions to reduce stigma associated with mental health problems. Due to the socio-political situation in general and in the specific context of COVID-19 outbreak, there is a need to integrate psychological wellbeing strategies in the university curricula. This will help students to combat the adversities they are constantly exposed to as well as serve as a solution to scarcity of specialized and community-based mental health services. Teachers training in identification and recognition of common mental health disorders, and basic counseling skills can also be integrated in usual teachers training.

Strengths and Limitations

This is the first study to systematically review the prevalence of depression among university students in Pakistan. We conducted meta-analysis to summarize prevalence estimates. We did not apply any restrictions on publication date to include as many studies as possible.

Our findings should be interpreted under the light of a few limitations. Studies included in this review used variety of screening tools, different sample sizes and screening tools cut-offs, that introduced substantial heterogeneity. Depression ascertainment methods employed by the most of studies in our systematic review were self-reporting screening tools. These tools do not provide clinical diagnosis. Most of studies did not report the psychometric properties for Pakistani population. We did not included gray literature such as non-published or non-peer reviewed studies in our meta-analysis, which may have introduced publication bias in present results. One more limitation of the current review is that we did not include any social factors for depression or co-morbidities in our analyses.

In this systematic review and meta-analysis, prevalence of depressive symptoms among Pakistani university students was found to be 42.66% with a huge variation among studies, however, there were very few good quality studies. Future research efforts should be directed to conduct large epidemiological studies for valid and reliable estimates of depression and to implement interventions to prevent and treat depression among university students.

Data Availability Statement

The original contributions presented in the study are included in the article/ Supplementary Material , further inquiries can be directed to the corresponding author/s.

Author Contributions

MNK and PA conceptualized and designed the study. PA, SI, and MNK performed the article search and data extraction. AW and MNK analyzed the data. AW, MNK, and PA interpreted the results. MNK and PA drafted the manuscript in support with AW and SI. All authors reviewed and approved the final version of the manuscript.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The reviewer SS declared a shared affiliation, though no other collaboration, with one of the authors AW to the handling Editor.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2020.603357/full#supplementary-material

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Keywords: depression, university students, Pakistan, systematic review, meta-analysis (as topic), low resource setting

Citation: Khan MN, Akhtar P, Ijaz S and Waqas A (2021) Prevalence of Depressive Symptoms Among University Students in Pakistan: A Systematic Review and Meta-Analysis. Front. Public Health 8:603357. doi: 10.3389/fpubh.2020.603357

Received: 06 September 2020; Accepted: 30 November 2020; Published: 08 January 2021.

Reviewed by:

Copyright © 2021 Khan, Akhtar, Ijaz and Waqas. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Ahmed Waqas, ahmed.waqas@liverpool.ac.uk

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Prevalence of depression and anxiety among general population in Pakistan during COVID-19 lockdown: An online-survey

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case study of depression in pakistan

  • Irfan Ullah   ORCID: orcid.org/0000-0003-1100-101X 1 ,
  • Sajjad Ali   ORCID: orcid.org/0000-0002-8024-5942 2 ,
  • Farzana Ashraf   ORCID: orcid.org/0000-0003-0110-2618 3 ,
  • Yasir Hakim 1 ,
  • Iftikhar Ali 4 ,
  • Arslan Rahat Ullah 5 ,
  • Vijay Kumar Chattu   ORCID: orcid.org/0000-0001-9840-8335 6 , 7 , 8 &
  • Amir H. Pakpour   ORCID: orcid.org/0000-0002-8798-5345 9  

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The present study's aim is to find the prevalence of two of the common indicators of mental health - depression and anxiety – and any correlation with socio-demographic indicators in the Pakistani population during the lockdown from 5 May to 25 July 2020. A cross-sectional survey was conducted using an online questionnaire sent to volunteer participants. A total of 1047 participants over 18 were recruited through convenience sampling. The survey targeted depression and anxiety levels, which were measured using a 14 item self-reporting Hospital Anxiety and Depression Scale (HADS). Out of the total sample population ( N =354), 39.9% suffered from depression and 57.7% from anxiety. Binary logistical regressions indicated significant predictive associations of gender ( OR=1.410 ), education ( OR=9.311 ), residence ( OR=0.370 ), household income ( OR=0.579 ), previous psychiatric problems ( OR=1.671 ), and previous psychiatric medication (OR=2.641) . These were the key factors e associated with a significant increase in depression. Increases in anxiety levels were significantly linked to gender ( OR=2.427 ), residence ( OR=0.619 ), previous psychiatric problems ( OR=1.166 ), and previous psychiatric medication ( OR=7.330 ). These results suggest depression and anxiety were prevalent among the Pakistani population during the lockdown. Along with other measures to contain the spread of COVID-19, citizens' mental health needs the Pakistani government's urgent attention as well as that of mental health experts. Further large-scale, such as healthcare practitioners, should be undertaken to identify other mental health indicators that need to be monitored.

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Introduction

In early December 2019, many cases of pneumonia caused by a novel beta coronavirus (the 2019 novel coronavirus) were identified in Wuhan, the capital city of Hubei, China (Guan et al., 2020 ). This virus has been named severe acute respiratory syndrome coronavirus2 (SARS-CoV-2), which displays phylogenetically identical characteristics to severe/acute respiratory syndrome coronavirus (SARS-Co-V) (Lu et al., 2020 ). The World Health Organization (WHO) declared COVID-19 a global pandemic on 11 March 2020, when the registered cases of COVID-19 reached 118,000, and the number of deaths reached 4291 in 114 countries (WHO, 2020 ). Amid epidemics, there is a growing sense of fear among individuals of becoming infected with viral diseases, which further causes anxiety and depression (Ahorsu et al., 2020 ; Hall et al., 2008 ). Anxiety is defined as the body's normal response to stress (Holland, 2018 ). Depression, on the other hand, is defined as a lack of interest in everyday tasks. It is hypothesized that persons who are exposed to a pandemic without immunization will experience anxiety, tension, and depression as a result of their fear of the unknown (in this case, the coronavirus) (Lin et al., 2021 ).

Since the outbreak of COVID-19, a large number of studies have been conducted on people’s mental health during lockdown and quarantine situations, particularly on ways to cope with the spread of these conditions. All the research has led to the conclusion that various restrictions to an individual’s behavior can have an adverse effect on their mental health. For example, a study conducted by Sprang and Silman ( 2013 ) showed that 25% of isolated parents and 30% of isolated children had symptoms of post-traumatic stress disorder (PTSD). A Korean by Jeong et al. in 2016 found that 7.6% of patients displayed symptoms of anxiety during the epidemic of Middle Eastern Respiratory Syndrome (MERS). In addition, similar results were reported in Canada during the 2003 severe acute respiratory syndrome (SARS) outbreak (Reynolds et al., 2008 ).

Fear, anxiety, desperation, and helplessness can be associated with epidemic outbreaks of infectious diseases, especially when infection and death rates are reported to be high (Ashraf et al., 2021 ; Rajabimajd et al., 2021 ). Tension spikes in the general population during infectious disease outbreaks, bringing not only poor mental health but also major economic consequences in the social and household sectors (Smith et al., 2019 ). The travel bans in China during the outbreak of SARS in 2003 and avian influenza in 2013 had a huge impact on the business sector and the jobs of individuals (Wishnick, 2010 ). The mental health of the general population can be affected by the COVID 19 pandemic and is of great importance from various aspects (Xiang et al., 2020 ). Due attention needs to be paid to the psychological traumas, and mental health problems experience in the general population. Controlling situations such as lockdowns can provoke anxiety responses and increase the fear and prejudice against infected and affected persons (Person et al., 2004 ). Studies examining the effect of COVID-19 on mental wellbeing not only highlight problematic areas but can also generate ways to provide health care services with the necessary information and support to deliver mental health treatment to those in need. Though a large number of studies have explored mental health in the particular context of mental health outcomes, yet there is a paucity of research assessing the prevalence of anxiety and depression symptoms relating to socio-demographic factors. Furthermore, the present study will be a valuable addition to the existing literature on the cultural aspect of mental health and depression.

Methodology

Study design and participants.

A cross-sectional study was conducted from 5 May to 25 July 2020 in Pakistan, targeting the general population. Online survey was accompanied by a self-administered questionnaire. The online survey was distributed by commonly used social media such as Facebook, WhatsApp and Telegram. Participants were also asked to share the online survey with their peers to obtain a more normal distribution and representative sample. To control the possible confounding factors, certain inclusion criteria were devised. Participants had to be (i) Pakistani nationals residing in the country since the outbreak of the corona pandemic, (ii) at least 18 years of age, (iii) able to speak Urdu as their first language, and (iv) not previously diagnosed with a psychological or psychiatric disorder or on any medications for the same. The exclusion criteria include: (i) Non- Pakistani nationals inside the country as well as Pakistani national living abroad, (2) anyone less than 18 years of age, (iii) anyone with a prior diagnosis of depression or anxiety disorder or any other mental health issue (iv) anyone who is on anti-psychotic or psychiatric medications. Dropouts and participants who provided insufficient or incomplete data were excluded from the study. The final sample comprised 1047 participants recruited through convenience sampling. The study was approved by the ethics committee of COMSATS University Lahore (REF: CUI/LHR/HUM/178) and carried out in accordance with the human research ethics outlined in the Helsinki Declaration 1975. The online survey comprised three sections; informed consent, demographic information, and study tools. Informed consent was provided by all the participants before completing the online survey. The participants were assured that their participation in the study was voluntary and were free to withdraw from the survey at any point without any privacy concerns. The survey remained anonymous to assure the reliability, replicability and confidentiality of the data

Demographic Questionnaire: With the help of a self-reporting standard questionnaire, socio-demographics parameters of the participants such as age, gender, marital status, education, region, area of residence, occupation, monthly household income, and smoker status were collected.

Hospital Anxiety and Depression Scale (HADS): The HADS was used to assess anxiety and depression in the study sample (Waqas et al., 2019 ). HADS is a valid measure for assessing mental health outcomes in terms of depression and anxiety and is widely used locally and internationally. The scale comprises 14 items equally distributed to assess anxiety (e.g., “I feel tense or wound up” ) and depression (e.g., “ I still enjoy the things I used to enjoy ”) through responses to statements. Two of the items are reverse coded (items 7 and 10) to cross-check the random responses. Each item is rated on a four-point Likert scale (0 to 3 with diverse descriptions for each item) with total scores ranging from 0 to 21. High scores are an indicator of a high level of depression and anxiety. Scores on HADS can be used on a continuum and as categorical as well (e.g., normal=0-7; mild=8-10; moderate=15-21 and severe=15-21). The present study showed a good fit for the alpha coefficient for total HADS (α=.85), depression (α=.72) as well as anxiety (α=.84) subscales.

Data Analysis

The data were analyzed using IBM SPSS Statistics V.26.0. All the data were coded in SPSS, and invalid data (e.g., random responses, incomplete responses, and repetitive responses) were dealt with using missing values analysis and outliers’ analysis in SPSS. We ran descriptive statistics -means, standard deviation, percentages, and frequency distribution - to estimate the descriptive characteristics of the study variables. First, the association between independent and dependent variables was determined using the Chi-square test of association. In addition, we ran logistical regression analyses to evaluate the degree of association of socio-demographic characteristics with depression and/or anxiety. The level of significance had a p-value < 0.05 and a confidence interval (CI) of 95%.

Of the total 1047 participants, a majority 550 (52.5%) were females and 497 (47.5%) were males. The vast majority (85%) of them were aged 18 - 30 years and the remaining (15%) were over 30 years of age indicating that the majority of the sample comprised of young adult population. The mean age (S.D) was found to be 25.76 ± 11.262 years which also indicates the higher use of social media platforms by this age groups. The participants resided in all provinces: 53.7% lived in Sindh, 22.5% in Punjab, 12.9% in Khayber Pukhtoonkhawah, 10.4% in Islamabad, 0.3% in Azad Jammu Kashmir, 0.2% in Gilgit Baltistan, and 0.1% Balochistan. More than 1/3 of the study participants (77.8%) were unmarried. Only 221(21.1%) were married, 6 (0.5%) were separated/divorced and 5 (0.4%) widowed (see Table 1 ).

Gender was found to be significantly associated with depression ( p<0.01 ) and anxiety (p=.001) . Education status was only significantly associated with depression ( p<0.001 ). Place of residence and occupation were significantly associated with both depression ( p<0.001 ) and anxiety ( p< 0.001 ). Household income was significantly associated only with symptoms of depression ( p<0.01 ). Previous psychiatric illness and previous psychiatric medications were significantly associated with depression ( p<0.001 ) and anxiety ( p<0.001 ) (Table 2 ).

Binary logistic regressions were performed to determine any predictive association of socio-demographics with depression and/or anxiety. The analysis indicated that gender, education, residence, household income, previous psychiatric problems and previous psychiatric medication are the key factors associated with a significant increase in depression among the participants with odds ratios of 1.410 [1.099-1.809], 9.311 [1.020-85.030], 0.370 [0.229-0.596], 0.579 [0.227-1.480], 1.671 [1.244-2.246], 2.641 [1.748-3.989] and 4.711 [2.416-9.187], respectively. In addition, gender, place of residence, previous psychiatric problem, and previous psychiatric medications were found to be the key factors associated with a significant increase in depression with an odds ratio of 2.427 [1.888-3.119], 0.619 [0.376-1.019], 1.166 [0.458-2.969], 7.330 [3.876-13.863] and 5.313 [2.236-12.629], respectively (Table 3 and 4 ).

Out of the total sample population, 39.9% suffered from depression and 57.7% from anxiety (Table 5 ).

The present study indicated the significant prevalence of anxiety and depression in a sample of the general population of Pakistan during the COVID 19 outbreak from 5 May to 25 July 2020. Our study findings suggest that being a woman with a lower level of education, living in an urban area, occupation, previous psychiatric illness, and medication were significantly associated with symptoms of anxiety and depression. Our study findings suggest that women were more likely to be anxious and depressed (67.8% & 43.8%, respectively) than males (46.5% and 35.6%, respectively) during the lockdown. This result is supported by a study conducted by (Farooq et al., 2019 ) in which females were 2.5 times as anxious and depressed as males (39.4% vs. 23.3%, respectively). Another research (Zahidie & Jamali, 2013 ) found that the prevalence of anxiety and depressive symptoms were 29% and 66% among women, compared to 10% and 33% among men. These findings are backed by studies conducted globally which report higher anxiety symptoms among females in China (Zhou et al., 2020 ; Hou et al., 2020 ), India (Varshney et al., 2020 ), Oman (Badahdah et al., 2020 ) and Spain (González-Sanguino et al., 2020 ). Plausible reasons for the higher prevalence of anxiety and depression among women could be biological factors, socioeconomic disadvantage, loss of social status, maladapted coping strategies, and the lack of a support system for women in this country (Mirza & Jenkins, 2004 ). Other well-known reasoning may be that most women have to balance their household work and professional workload due to the inherited socio-cultural norms that still prevail in Pakistani households. Males are barely involved in household activities. As men spend more time at home due to the ‘stay home, stay safe’ policy of the government, the workload burden of the women in the household increases.

Moreover, anxiety and depression can be seen as more prevalent in urban and semi-urban locations. This could be because COVID-19 is more prevalent in urban settlements. Lockdown has had a great impact on all the densely populated cities of Pakistan, putting all the lives of the people living there on hold. Anxiety and depression can be significantly associated with the employment status of the general public, a local reflection of the hundreds of thousands of jobs being lost across the world. Pakistan’s Ministry of Finance revealed 3 million jobs had been lost during the COVD19 outbreak (Gulf news, 2020 ). The findings are supported by a Chinese study which showed that the prevalence of psychological health problems are more common among urban residents due to a great number of COVID-19 cases among cities and urban areas acting as epicenters of the diseases (Liu et al., 2021 ). Salary cuts and reductions in new jobs are expected. Moreover, uncertainty and possibly fear could have led to the development of more depression and anxiety symptoms. In addition, offices have been shut down because of the travel ban, and most employees are working from home. Lack of contact with co-workers could affect workers' motivation, satisfaction with work, and productivity. Not being able to meet deadlines and targets due to only earning hand of house and the usual pressure may cause a rise in anxiety levels among them.

Furthermore, household income is significantly associated with depression in the participants. The lower the household income, the more indicators of depressive symptoms there were. Sareen et al. ( 2011 ) found that low levels of household income are associated with mental disorders and suicide attempts, and a reduction in household income is associated with an increased risk of mental disorder incidents. One possible explanation for this could be that the lockdown imposed has disrupted the economic flow throughout the country.

Our results suggest that there is an increased prevalence of depression and anxiety among people with previous mental health problems and/or who were on medication for psychiatric disorders (p<0.001). One of the reasons for this is that the widespread lockdown has meant psychiatric patients are unable to contact their doctors in times of need. The closure of all psychiatric OPDs (Dawn news, 2020 ) and the current chaotic situation due to COVID-19 has increased the severity of some patients’ psychiatric conditions, leading to a spike in depression and anxiety among them. Also, being unable to travel and get medications during the lockdown is a reason for the spike.

Monitoring the mental health of populations during a pandemic is crucial, as public fear and fear induced by over-reacting behavior could act as a barrier to the control of infectious diseases (Dong & Bouey, 2020 ). In addition, the existing stringent lockdown measures and the uncertain period of home isolation reflect an ongoing traumatic occurrence that could potentially contribute to substantial long-term health costs. Therefore, epidemiological monitoring and targeted intervention should be introduced in good time to avoid more mental health issues in the future.

Limitations of the Study

Along with the strong evidence this study has highlighted, there are some limitations and bias which are common with any cross-sectional study. Firstly, the researchers did not go into the field to collect data but used electronic means during the lockdown since the public health regulations were in place. Since the participation was voluntary, only the young adults who were active on social media had more participation resulting in lack of representation of all socio-demographic features. Therefore, the results cannot be generalized to the entire population of Pakistan. Secondly, most of the study sample was from 18 to 30 years of age leaving the gaps for the middle aged and older age groups. Thirdly, considering the high illiteracy rate of Pakistan, our sample size was mostly made up of a literal population. All of these factors mean the results are not generalizable as representative of the entire population. They do, however, offer important indicators, likely to be shared more generally,

The present study reported the high prevalence of depression and anxiety in participants from a broad spectrum of the general population of Pakistan during the country-wide lockdown due to the COVID-19 pandemic. Mental Health Ordinance 2001 in Pakistan preserves the rights of citizens dealing with mental health issues and guarantees to take care of them. In these difficult times, the government of Pakistan should make mental health care one of its top priorities. Pakistan's government is doing its best to reduce the spread of the pandemic in the country; however, effective steps should also be taken for the care of mental health of its citizens.

Availability of data and materials

The data set is available upon request from the corresponding author.

Abbreviations

Coronavirus outbreak

Hospital Anxiety and Depression Scale

Severe acute respiratory syndrome coronavirus2

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Kabir Medical College, Gandhara University, Peshawar, Pakistan

Irfan Ullah & Yasir Hakim

Ziauddin Medical University, Karachi, Pakistan

Department of Humanities, COMSATS University, Lahore, Pakistan

Farzana Ashraf

Paraplegic Centre, Hayatabad, Peshawar, Pakistan

Iftikhar Ali

Department of Medicine, Northwest general hospital and Research Centre, Peshawar, Pakistan

Arslan Rahat Ullah

Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5S 1A8, Canada

Vijay Kumar Chattu

Center for Transdisciplinary Research, SIMATS, Saveetha University, Chennai, India

Department of Community Medicine, Faculty of Medicine, Datta Meghe Institute of Medical Sciences, Wardha, India

Department of Nursing, School of Health and Welfare, Jönköping University, Gjuterigatan 5, 553 18, Jönköping, Sweden

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IU and SA have made substantial contributions to the conception and design. FA, YH, IA, and ARU participated in the study design and data acquisition. IU, SA, VKC and AHP were involved in drafting and revising the manuscript. VKC provided critical comments and re-edicted the final draft. All authors have read and approved the manuscript.

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Ullah, I., Ali, S., Ashraf, F. et al. Prevalence of depression and anxiety among general population in Pakistan during COVID-19 lockdown: An online-survey. Curr Psychol 43 , 8338–8345 (2024). https://doi.org/10.1007/s12144-022-02815-7

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Resilience and prenatal mental health in Pakistan: a qualitative inquiry

  • Shireen Shehzad Bhamani 1 , 2 ,
  • David Arthur 3 , 4 ,
  • An-Sofie Van Parys 2 ,
  • Nicole Letourneau 5 ,
  • Gail Wagnild 6 ,
  • Shahirose Sadrudin Premji 7 ,
  • Nargis Asad 1 , 8 &
  • Olivier Degomme 2  

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Women in Pakistan suffer from a high rate of depression. The stress of low-income, illiteracy, exposure to violence and living in a patriarchal society are predisposing vulnerabilities for depression, particularly during and following pregnancy. The resilience of an individual plays a significant role in promoting prenatal mental health, but this has yet to be thoroughly researched. In this article, our objective is to identify the core characteristics of resilience among pregnant women, which will then help us in developing an intervention.

The exploratory-descriptive study was conducted over 6 months in five different antenatal hospitals in Sindh, Pakistan. A total of 17 semi-structured interviews were conducted with pregnant women, purposefully selected with heterogeneous characteristics to explore diverse perspectives, while symptoms of depression were quantified by the Edinburgh Postnatal Depression Scale before the interview. Verbatim transcriptions were coded openly and merged into categories and themes.

A total of six themes emerged from in-depth thematic analysis: 1) purpose of life, 2) dealing with emotions, 3) believing in yourself, 4) optimistic approach, 5) strengthening support and relationship and 6) spirituality and humanity. Women agreed that these characteristics could help them improve their mental health.

In conclusion, these themes were the core components of pregnant women’s resilience which ultimately could help to promote prenatal mental health. These pave a pathway towards developing culturally and contextually resilience interventions aimed at enhancing mental health of pregnant women which then may improve neonatal and family mental wellbeing.

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Depression during pregnancy is a global concern [ 1 , 2 ] complicated by associated socio-demographic factors such as income, education, age, personal history and pregnancy complications [ 3 ]. Ongoing negative outcomes include maternal mortality and compromised child health [ 4 ]. Studies conducted in low- and middle-income countries (LMICs) reveal symptoms of depression ranging from 12.7 to 37% at some point during pregnancy [ 2 , 5 , 6 , 7 , 8 ]. In a rural sub district of Pakistan where 1154 pregnant women were sampled, the prevalence of depression was over 26%, [ 9 ].

In LMICs, predictors of prenatal mental illness including depression consist of financial constraints, stress regarding the sex of the baby, conflicts with mother-in-law or husband, and poor family support [ 10 ]. Other studies point to the stress of low-income, illiteracy, exposure to violence and living in a patriarchal society as key factors increasing vulnerability to depression [ 11 , 12 , 13 , 14 , 15 , 16 ]. In Pakistan, where depression is highly prevalent, various pervasive risk factors increase the likelihood of mental illness, such as lack of economic and social support, being an unemployed woman, lack of education and domestic abuse [ 17 , 18 ]. In a broader context, societal norms, socioeconomic environment, and cultural taboos all have a substantial impact on the mental health of pregnant women [ 19 ]. Hence, it is evident that the predictors vary from an individual to a societal level, which increase vulnerability to depression [ 20 ].

Depression during pregnancy can have repercussions in later life for the mother and present as eating disorders, post-traumatic stress disorder, and personality disorders [ 21 ]. Furthermore, despite the high prevalence of depression in low- and middle-income countries, mental health management is stigmatized [ 22 , 23 , 24 ]. Such stigma may compound lower self-esteem issues in these women, and decrease their help seeking behaviour [ 25 ]. Depression during pregnancy can also negatively impact child health outcomes. In Pakistan, low birth weight, growth retardation, and delayed cognitive and motor development are some of the outcomes associated with children of depressed mothers [ 26 , 27 ].

Perinatal care to ensure safe pregnancy and childbirth planning has a positive impact on health-seeking behavior and it reduces the risk of illness during pregnancy [ 28 ]. Prenatal mental health care is an important component of this yet limited mental health resources or lack of availability of health care facilities make it difficult for women to seek appropriate mental health care. Exploring resilience during pregnancy may help to better understand how to promote Pakistani women’s mental health throughout pregnancy. Individual’s resilience, which is defined as one’s ability to cope with a stressful situation, can function to reduce the risk of mental illness [ 29 ] including depression in pregnant women. Interestingly, pregnancy is a period during which resilience extends from the individual level and becomes of particular importance when considering the impact and the woman’s role in family and society [ 30 ]. The context surrounding pregnancy can either act as a protective shield or contribute towards stress because social and familial support can help with coping, the social and family environment during pregnancy can operate as a protective factor. In a similar way, the pregnant woman may be more vulnerable if there is no supportive environment [ 30 , 31 ]. According to the resilience governance framework, resilience is the capacity for adaptation, absorption, and transformation related to a stressful event [ 32 ]. In other words, resilient people are able to manage stress and reduce symptoms of depression [ 33 ], enhancing positivity which enables an individual to think freely, creatively, and solve problems; hence manage the stressful situation and pregnancy process effectively and in a healthy way [ 34 , 35 ].

A study conducted in Europe with 151 pregnant women identified that those who were resilient scored higher on self-acceptance, had greater psychological wellbeing, and rated lower levels of pregnancy related stress and postpartum depression, as compared to those who scored low in resilience [ 36 ]. Similarly, other studies done in LMIC have also concluded that resilience factors act as a buffer and coping mechanism against stress and depression [ 3 , 37 ]. Moreover, women may possess a significant capacity to care for their family and the home. The role of a woman is a collection of responsibilities that she may perform to provide resources for her husband, children and others [ 38 ]. A meta-synthesis of 15 countries found that women living in LMIC are expected to perform major household tasks without any compensation and are constrained from making health decisions in the family [ 39 ]. This role has a special significance when a woman is expecting, thus assisting a particular woman in learning good, constructive skills may have an impact on her personal health, family, and community.

Given that resilience has a very broad definition, examining it without a frame of reference is challenging, so the current study will rely on the ecological framework proposed by Bronfenbrenner. Which was strategically organized into four tiers of external impacts (microsystem, mesosystem, exosystem, and macrosystems) [ 40 , 41 ], Each of these systems can influences behavior and health of an individual [ 42 ]. Microsystem refers to individual factors and their interactions; mesosystem refers to the relationship with various settings in which the individual is involved; exosystem refers to forces within the larger social system in which the individual is embedded eg unemployment while macrosystem refers to cultural beliefs and values that can influence other system. Pregnant women will undoubtedly confront societal, cultural, and familial pressures during this time, which fits within the definition of the ecological model and encourage exploration of these systems as component of resilience and enabling the development of a culturally and contextually acceptable health promotion intervention [ 30 , 43 ].

In vulnerable groups of pregnant woman, with appropriate screening, the opportunity exists to better understand what enhances resilience with the possibility to improve potential, strength, courage and meaning to life, as these individuals develop new abilities to respond to stress [ 44 , 45 ]. The most appropriate and practical approach for this study is to explore the attributes of resilience to develop an intervention which can help women in creating their own set of skills and techniques that are immediately and directly applicable to their daily lives throughout their pregnancy to promote mental wellbeing. As there is limited literature reporting on resilience during pregnancy, in either high-income countries or LMICs, the objective of current paper is to identify the core characteristics of the resilience that pregnant women develop which ultimately could help to promote mental health.

This is part of a larger project, which will be conducted in a two-phased approach. This paper focuses on phase one and describes the qualitative inquiry to explore the resilience core attributes. These findings will be used to guide the development of resilience building intervention, which will be carried out during the second phase of the larger project using a randomized-controlled trial to evaluate the developed intervention among pregnant women.

Research design

This qualitative inquiry was conducted using an exploratory- descriptive study design which highlighted the experiences and resilience attributes in a sample of pregnant women in Sindh, Pakistan. Over a period of 6 months from May to October 2019, face-to-face interviews were conducted in the local language Urdu, in a safe private room. The interviews lasted 45–60 minutes and were tape recorded after receiving written informed consent. Observational notes were also made during the interview.

Study setting

Participants were recruited from the antenatal clinics of the four secondary hospitals of the Aga Khan University Hospital (AKUH) in Karachi, Pakistan. AKUH is a private not for profit institution, serving patients with mixed ethnic and socio-economic backgrounds, from different regions across the country. We also included one other hospital, Koohi Goht (KG) Hospital of Karachi, which provides a midwifery-led service to the most vulnerable women in the community from low socio-economic strata. The rationale for selecting these five settings was purposeful, to ensure a rich database from different socio-economic and ethnic groups, reflecting the cultural diversity that exists across Karachi, Pakistan.

Sampling strategy and recruitment

Permission was obtained from the heads/representatives of all five sites, staff were informed about the research and written consent was obtained from participants. The purposive sampling technique was used to intentionally select participants for interviews to attain the perspectives of a diverse group of participants from wide-ranging of settings and experiences. Purposive sampling based on criteria allows us to accomplish the study’s objectives while lowering selection bias [ 46 ].

Seventeen participants were recruited from the five sites, using the information provided by their head or representatives based on our eligibility criteria. Our eligibility criteria enabled us to obtain a sample that accurately represented the target population. The 13 participants from the four AKU secondary hospitals were initially contacted by telephone for consent. Six of the 17 individuals were also involved in an ongoing study [ 47 ]. The remaining four participants from KG were recruited from the waiting area of the hospital. All participants were briefed about the research and similar procedures were followed. After 17 interviews, data collection was stopped due to the repetition of information and confirmation of previously gathered data, which indicated data saturation.

Eligibility criteria

Participants who were 18 years of age and above, married, at a gestation of 12 weeks and above, and able to speak and understand Urdu were recruited.

Description of materials

Participants were asked to: 1) complete a demographic questionnaire; 2) complete the Edinburgh Postnatal Depression Scale (EPDS); and 3) engage in a face-to-face semi structured in-depth interview. Depression symptoms were measured by the EPDS Scale, and resilience attributes were explored through interviews. The EPDS has 10 items (each scoring 0–3) with total scores ranging from 0 to 30 and is widely used and shown to be reliable and valid for use in pregnancy [ 48 ], and in Urdu [ 49 ]. Higher scores indicate greater symptomatology with scores of 10 or more indicating “at risk” for depression, while scores of 13 or more identify depression consistent with a physician diagnosis of major depressive disorder [ 50 , 51 , 52 ]. To identify participants with depressive symptoms from mild to serious, 10 was adopted as the cut-off score. The demographic questionnaire included items assessing age, education, language, family (nuclear/extended) type, marriage details and reproductive history.

Interview guide

The guide was developed by the research team based on a comprehensive review of the literature, and an existing conceptual framework of resilience underpinning Wagnild and Young’s Resilience Scale [ 44 , 45 ]. This resilience scale is frequently used in studies about the resilience conducted in Pakistan, and the scale has been validated for use among Pakistani married women [ 53 , 54 , 55 , 56 , 57 , 58 ]. The principal investigator (PI) of the current study performed this validation while carefully taken into consideration the content and cultural biases [ 44 ] which measures the following five attributes that strengthen an individual’s capacity for resilience: 1): an understanding of the meaning of life; 2) perseverance/determination; 3) existential aloneness/friendship with self; 4) equanimity and 5) self-reliance. The interview guide was then verified by the authors (SSB, DA, AS, NL, SSP, GW and OD) who have vast experience in the field of mental health, perinatal health, and qualitative research. (Refer Table  1 ).

Data analysis

Using thematic analysis, data were manually analyzed from multiple sources including listening to recorded audios, reviewing transcriptions, field notes, and reflections of the researcher to increase validity of data and decrease researcher bias. The research team members that were closely engaged in data analysis and management were SSB, DA and AV.

The following steps were adopted:

Use of the bracketing technique in which researchers consciously put aside their biases related to the study before commencing interviews so that the data are collected without judgment [ 59 ].

Reflective notes were written after each interview and shared and discussed with the research team. This helped in identifying recurrent themes during analysis [ 59 ].

The interviews were conducted in Urdu and audio recorded, transcribed in Urdu and then translated into English. Back translation into Urdu followed and comparisons were made with the original Urdu transcription to detect any discrepancies in translation. This added validity to the audio recording and transcription process.

Open coding was done manually from transcriptions by the research team members. From the participants’ quotes/verbatim, codes were allocated, then related codes were merged or grouped into separate categories, and then associated categories were finally aggregated into one theme.

Hence, one researcher (SSB) initially coded the transcripts. However, throughout data collection and analysis, codes, categories, and themes were created and agreed upon in discussions with the qualitative researchers (AV and DA). They independently coded the transcripts of random interviews and then carefully and constructively examined the initial coding to compare and analyze the results. Interviews proceeded until there were no more new themes emerging from the data or when data saturation was reached. The entire research team shared and reviewed all findings before deciding on the final coding and thematic framework.

The mean age of participants was 27.9 years (standard deviation (SD) 6.912, range 16 to 39 years). Mean gestational age was 30.8 weeks (SD6.84), rangefrom 16 to 40 weeks). All participants were married (duration ranged from less than 1 to 23 years), and only two were working (one doing office work and the other working from home doing stitching). Despite the diversity of their first languages, which reflected their ethnicity and region of residence, all participants were proficient in Urdu. (Table  2 ). Notably, nine participants (53%) were rated as having symptoms of depression on the EPDS.

Our main qualitative findings identified six themes that emerged from the data which exemplify resilience attributes and included: 1) purpose of life; 2) dealing with emotions; 3) believing in self; 4) optimistic approach; 5) strengthening support and relationship; and 6) spirituality and humanity (Fig.  1 ).

figure 1

Themes and Categories

The following section reports the essence of the themes which emerged, and sub sections present the categories, which include verbatim expressions upon which themes are built. Each participant’s response is coded alongside their depression assessment where “D” stands for women with depressive symptoms and “ND” for women without depressive symptoms as measured on the EPDS.

Theme 1: purpose of life

Overall, these women were living life without specific purpose. Their goals lacked direction and they explained how they were only living their lives for their families. Many struggled to respond to the probes about their future goals - they were not certain and seemed not to have thought about this before. Their lives revolved around their husbands and children and the majority had little ambition or goals of their own. However, some women were quite clear and confident while sharing their life stories, with a spark in their eyes as they related cherished memories.

No personal goals

Most of the participants shared that they felt little ambition and passion towards anything, and their purpose of life was associated with their family, husband, and children. For example, three different women stated: “Now I just think that marriage and children is the only thing left……taking care of children, and their good upbringing, this is my only purpose” (KH01- D). “To look after husband, to look after mother-in-law, to look after parents. I am doing all this and will do with Allah’s will” (GDN03- D). “The purpose of my life is that I want to see my son join the army” (KH03- ND) .

Some participants shared clear goals for themselves, but their ultimate goal centered around others only, for example one of the participants said, “I want to get a diploma, and this is for my children’s future.” (KA02-ND) and another stated her life was oriented and goal directed: “I want to spend life in a proper manner, I want life to be organized.” (KG04- ND). One participant was clear that “I want to please Allah, to offer prayers, do good deeds, so everyone can stay happy because of me” (GDN01- ND) .

Theme 2: dealing with emotions

Most of the participants had difficulty in expressing and managing their emotions. Their selection of words and the body language showed resistance, such that they were not able to make eye contact. A minority were able to express themselves openly and were clear and fluent in their communication. Stress was an issue for several participants who shared their anger and stress management issues and wanted to learn to manage their stress and aggression.

Managing stress

Few of the participants showed keen interest to learn how to manage their stress as they shared their experiences and were open to learning coping mechanisms. They were aware of their own emotions and wanted to adopt a more positive approach. Two mothers captured the essence of this theme: “I want to deal well with stress…I want to manage the stress my parents have in their life.” (HYD02- ND) and “We must solve the problems that come our way. There is no point in getting tense.” (KA02- ND).

Dealing with thoughts and emotions was an issue which emerged. The ability to comprehend feelings, to express them in words and the struggle to manage them was expressed. Anxiety was evident in their body language - one of the participants cried during the interview and many of them needed constant support from the researcher. They struggled to find words to express their worry. Two women strongly expressed the issue: “My mind is filled with the thoughts that he will leave me some day; I am afraid of losing him” (GDN03- D). “There are some people in my in-laws who don’t behave well with me, I wondered, why did this happen to me only” (KG03- D) .

Dealing with anger

Participants’ responses suggested they were struggling to manage their anger. Anger issues were evident and distressing for most of the participants and voiced clearly: “I have a lot of bad things in me, my anger, sometimes I think due to my anger I will get into trouble too. I used to break things; I get abusive too” (GDN03- D). Other participants stated: “My family tells me that I am perfect in all aspects, but I get angry very easily…. I take care of everyone and that I get angry, and all my efforts get useless. My husband says, ‘that you do a lot for everyone but your anger ruins everything.” (KA02- ND).

Some participants shared their struggle to manage their emotions, which ended in self harm. Some expressed suicidal ideas: One participant while talking about the dissatisfaction with her marital life shared that “ This shattered me so much that I wanted to die, and I even went and contemplated suicide at a bridge near Clifton.” (GDN03- D) . The other participant also shared that, “I harm myself and do nothing to anybody else… all anger is inside me I never take it out” (KH01- D).

Some of the participants’ responses showed courage and readiness to address their daily life problems and tried to deal with their stressors in a positive way. The participants pointed out that “I take everything in a positive way, I know that this thing is negative even then I try to take it as positive” (HYD02- ND). Another demonstrated courage and stated: “I understand that life goes on, there is no point in crying, because only I will get hurt by this. I will pressurize myself and will never come out of it. So, I must move on” (KH03- ND).

Exploring ways that the participants managed with their anger and stress, revealed that some of the participants tended to use humor to deal with stressful situations. Humor helped to cope with stressful circumstances and maintain relationships with others and this was reflected in three participants’ comments: “when I make others happy, I feel satisfied ” (HYD 02- ND); “Making others laugh so that they feel good…. and they get peace of mind” (KH03- ND) ; “I tell them funny things, so they laugh and in return I feel good” (KA02-ND) .

Theme 3: believing in yourself

When participants were asked to whom they give credit for their achievements, the majority mentioned their parents, husbands, and siblings - none of them appreciated themselves for their good deeds. It was noted that the cultural practice of not praising oneself in front of others was stopping these women from sharing their qualities and strengths. They openly talked about their flaws and drawbacks but when asked to praise themselves, were reluctant, resulting in them feeling unappreciated for their efforts.

Not giving credit to self

Most of the participants shared that they never give credit to themselves for their achievements as one of the participants stated that, “I will give it to my parents” (KH01-D), the participant also stated that she gives credit for her achievements to, “To my husband… To my parents… They made me so capable that other people responded to me like this (positively). If they don’t make me this much capable, then others will not admire me” (KG01- D).

On the contrary, few of the participants had confidence in themselves and their achievements and gave credit to either themselves or to God. They boldly stated that …little to myself, some to husband and mother” (GDN-P0- ND) . Few of them also gave credit to the divine power and did not want to praise themselves so they stated, “I give credit to Allah. Whatever happens good or bad it’s because of him.” (KH03- ND).

Self-blaming

All participants appeared to blame themselves for every mishap or failure that occurred whether this was related to her or not. As mentioned by two of the participants, “…because of my own mistakes …. maybe something is missing in myself…. or fault in myself…. that’s why these things happen (KA01-ND) and the other one also stated, “…my own self, whatever happens that is wrong, it was due to me” (GDN01-ND).

Self confidence

When participants were asked what is necessary in life to be strong and independent, few of them shared that confidence and valuing oneself is essential: “Must be confident, don’t stay at the back, feel proud of yourself...don’t be bound.... Confidence is very necessary, otherwise the girl has no value” (KA03- ND) . The other one shared that, “I realize that a person can do everything if s/he wants.” (HYD02- ND).

Responses from some of the participants reflected that they lacked self-confidence and courage to stand for themselves and face domestic violence further and that they seemed to struggle to voice their basic rights which has impacted on the self-image of some of the participants. As two of them quoted that, “When it was my 17 month [of pregnancy] my husband beat me…. then after that...threw me out from home. I had my may baby at 32 weeks”. (KH01- D) and the other participant reflected that, “…it’s been ages since I have seen my face in mirror…. the face is not the same as it used to be…. I am not like before…. my complexion got dull” (KG03- D).

Decision making power

Participants felt more empowered to make decisions before marriage. Most of the participants expressed that after marriage, they consulted their husband and in-laws in every decision. According to cultural values, when one becomes part of a family, everyone’s opinion must be considered. Upon asking this participant pointed out, “Make decisions…but with everybody’s suggestion….by asking everyone, is this right? or that is right like this” (KA01-ND) , “you don’t know which decision will hurt them, so you have to share before making any decision” (KA03- ND).

Some of the participants showed helplessness and dependency, one participant stated her desire to make decisions as, “I want to take my own decisions myself, but I cannot” (KG03-D) .

Theme 4: optimistic approach

In this study participants were asked what keeps them going with life and helps them in dealing with the adversities that life brings. Most shared that hope and positivity motivates them to survive and thrive for the best. Moreover, they also expressed their optimistic approach in life due to feeling satisfied and content. When asked to list the ways they deal with life events, few participants identified positive coping strategies whereas, others lacked this ability and were not able to answer despite constant probing by the researcher. A positive attitude and evidence of resilience attributes were evident in the participants who scored low on the EPDS.

Being positive

Upon asking what makes them feel content and fearless in their lives, some of the participants shared that having positive mindset and ignoring the negativity helps them in dealing with stressful situations. These participants demonstrated lively personalities during the interview and stated, “I like positivity in myself which I learnt from my father, I am broad minded. (KA03- ND)”, and “…don’t take things seriously. Whatever people say unnecessarily just ignore it…as I have done for some time” (KA01-ND) .

On the contrary, most of the participants showed sadness, hopelessness, and helplessness when asked about life’s ups and downs. Two participants responded, “ While in my work life a few periods went well, few periods were full of depression…I became frustrated and obsessed” (KG-01 D) and “I went into depression because of my husband’s behavior” (KH-01, D).

Being courageous

Most of the participants shared that being courageous and bold helped them in managing negative emotions and they said that at times one should take a stand for herself. One of the participants shared her feelings, “when difficult times come to any person…that person showed courage…so she can easily pass that time” (KH01-D) . The other pointed out that, “One should have courage and strength, there is no way out if you don’t have courage, people should keep trying, there must be a way out, find a solution with courage and don’t consider yourself weak.” (GDN01-ND) .

Being hopeful

Some of the participants were very hopeful regarding their future and that is what helped them in staying positive. Hope gave them light and direction to keep on moving with what life brings for them. As mentioned by one of the participants, “one should keep trying because if you run away from the situation then that situation might convert into a big trouble which then will not be easy to deal with.” (KA03-ND) . The other participant stated that, “I understand that life goes on, there is no point in crying, because only I will get hurt by this. I will pressurize myself and will never come out of it…so I must move on” (KH03-ND) .

On the other hand, few of the participants were restricted in living according to their own will, this made them feel helpless and stranded. The lack of support from family made them believe that now this is their life and they had to live this way only. As shared by few participants, “My husband never allowed me to do any job, from the beginning I did alma [religious scholar] course, did my studies, did a beautician course, I wanted for everything, I wished that I wanted to this and that but I couldn’t” (KH01- D) and “A woman stays in the house, what else can she do….a woman stays at home and does home chores, it’s her duty” (KG03- D) .

Happy and contented

Most of the participants shared the importance of being happy in all situations and expressed that no matter what happens one must always seek happiness in life. Participants reflected upon the importance of staying happy but few of them were not able to experience contentment or happiness. One reported, “I try to stay happy in every situation, but situation doesn’t allow me” (KG03-D) while another stated “ it’s a natural behavior, if you are happy today then, some other day you will feel sad too it’s a common fact” (KA03- ND).

Life Goes on

Most of the participants were optimistic as they shared how ups and downs are part of life, and we must be able to deal with all the situations. They also expressed how with time everything gets better, so one must not lose hope and always try to stay positive, and that courage and being strong keeps you motivated. Two responded positively by saying, “We must go on with life, and this is god’s will to give life and death…. Life goes on. We must move forward in life (KH03-ND), and that “Time heals everything” (HYD01- ND).

Theme 5: strengthening support and relationships

Women enrolled in this study struggled with their relationships and that created stress expressed as concerns of extra-marital affairs, abuse and lack of trust in relationships that have impacted their mental health. However, some reported sharing a good bond with their in-laws and husband.

Family role in maintaining relationships

Some of the participants had good relationships with their in-laws and husbands, but many others had a tumultuous and difficult relationships. Moreover, a few of the participants shared how husbands play an important role in their life and maintaining a strong relationship is important for their peace of mind. Two participants shared, “My in-laws used to live with me, and everyone respects me. I am the youngest, but everyone respects me” (KA02-ND) and “this husband-and-wife relation is the strongest bond, if they are together, they can solve every problem…. If a husband falls anywhere in life, then the wife is here to hold him, same is for the husband, if the wife falls then he should hold her; they are together, a strong bond” (KA03-ND) .

Most of the participants expressed a lack of support from in-laws and husband. They were struggling to have a positive relationship especially with their husbands. One of the participants stated that, “My husband will believe others, even a child and will scold me, he never supports me” (GDN02- D) . The other shared her sorrow as, “My husband insulted me in front of my family members, in front of the whole society” (KH01-D).

Balancing relationships

When asked to share their thoughts on how they manage their relationships effectively and the difficulties in doing so, participants shared their view on the importance of balancing relationships. Few participants stated that, “I cannot maintain equality; my husband says this too that I cannot maintain equality among all”. (KG04-ND) . Another participant pointed out that, “Even my husband tells me that you are not looking after your house.” (GDN03- D) . Considering this, researchers noticed that all participants placed an emphasis on maintaining positive relationships with all family members and taking care of domestic duties.

Unrealistic expectations

It became clear that unrealistic expectations are the cause of distress among relations and that not meeting the expectations creates misunderstandings. Most of the participants shared similar responses, “My husband never allowed me to visit my parents’ house…even our homes were in front of each other….”(KH01-D), “that is the reason my husband fights, that you only get ready when you go out”.(GDN03-D) , “My husband once said he wants to get married again as I am not able to give him child, my heart breaks into pieces” (GDN02-D).

Theme 6: spirituality and humanity

Participants were able to deal with stressors more effectively due to their faith and trust in the divine power. They shared that faith in God was a major source of hope and gives them strength to deal with the stressful situations.

Faith & trust

When asked about spirituality, participants reflected that, “Whenever hard times come, we go with that and Allah helps us too, it is stressful, sometimes people get hopeless, but then again, Allah, he will give you strength, he will give you a solution.” (GDN01- ND) . Few participants shared their believes and stated that “I believe that whatever happens, happens for good. We must stay strong, it’s upon Allah to give life and death. I trust Allah more than anyone. I always thank Allah, whenever I am in trouble, or I am in peace.” (KH03- ND). One more participant shared that “I take every problem as an exam as it is from Allah, you have to be faithful in this regard,” (HYD 02-ND).

Some of the participants expressed that they trust people easily and have difficulty in analyzing the situation and staying positive. One of the participants stated her vulnerability as, “I trusted people very easily (GDN03- D).

Gratitude towards Allah

Being thankful can sometimes be a great blessing and gives internal power to women. Majority of the participants shared that showing gratitude has helped them in life. Few of the participants expressed that “When I am alone, I just pray, Allah is merciful, he will not leave me, he will support me, Thanks to Allah many people did bad to me, but I never complained to Allah.” (GDN02-D) , “I always thank Allah, whenever I am in trouble, or I am in peace I thank him only”. (KH03-ND) , “I just thank Allah and remain patient for what I don’t have”. (HYD 02-ND).

Most of the participants expressed that by helping others, they felt more connected, contented, and competent about themselves. Further, they shared that helping others is a good deed and one must think about others as well, few participants commented that, “According to me those people are good people who assist others, who help them in their problems (GDN01- ND), “When people get happy, they give prayers (GDN03-D) and “I keep others happy so that’s why it may be… No, I mean that never think bad about anyone, always think nice about everyone”. (KA02-ND) Another participant highlighted that “Love is the most important thing, if someone comes to you, you should give love so that the person forgets about her past while sitting with you” (GDN03-D) .

Utilizing in-depth interviews this study explored the experiences and resilience attributes which enhance the prenatal mental health in a sample of 17 Pakistani women who represented women with and without depressive symptoms. The six emergent themes: purpose of life; dealing with emotions; believing in self; optimistic approach; strengthening support and relationship; and spirituality and humanity were viewed as factors enhancing resilience during stressful situations. Although, all the participants belonged to diverse background in terms of education, working status, and other factors some emerged as being less depressive compared to others. Interestingly, whether the women showed depressive symptoms or not, they voiced similar resilience attributes which they believe are important for improving their mental health.

Three recent studies conducted with pregnant women in high income countries also reported similar findings. Firstly, a study in Alberta, Canada used thematic analysis to explore the resilience practices and strategies of 54 pregnant women that supported them during traumatic experiences. These emerged as: “Relationships”; “Emotional Regulation”; and “Optimism” [ 60 ]. The results showed that remaining calm and regulating emotions helped in healing trauma, while developing a positive approach and having an optimistic outlook towards life helped participants to shift their beliefs when dealing with stressful situations [ 60 ]. Secondly, Gallagher et al. [ 61 ] in their quantitative study of 329 women in the USA found that people who are optimistic tend to adopt a positive coping strategy as compared to those who are not optimistic, and this uniquely contributes to enhancing a person’s resilience [ 61 , 62 ]. Obviously, there are more components that affect the resilience of an individual but effective use of the identified attributes during pregnancy, clearly a stressful experience, is proposed to mediate an individual’s reactions and responses [ 63 ]. Hence, having a strong support system, approach and emotional regulation that deals with internal and external locus of control are all components of resilience. Thirdly, a qualitative study conducted in the USA recruited 10 mothers and pregnant women exposed to intimate partner violence and 46 service providers. Results identified that participants who had high self-esteem or positive self-perception were found to be more resilient and were able to deal with stressful situations in a more effective way. High self-esteem, the strong support of friends and family and greater empathy, forgiveness, and compassion guided them in strengthening their resilience [ 64 ]. Self-esteem as an important aspect of resilience was also articulated in a study, which was conducted among Chinese adolescents where internal factors such as self-esteem were a major source of increasing resilience in an individual [ 65 ]. I Considering previous findings from research in which more than half of pregnant women in Pakistan demonstrated low self-esteem [ 66 ], .a positive self-belief would be a key factor in building resilience.

The current study also revealed that paternal involvement and support from the paternal family kept women hopeful. Moreover, women who expressed their goals with clarity were found to be self-sufficient and self-reliant which is one of the attributes of resilience. A study conducted in southern Louisiana, USA, also shared similar findings. Despite teenage pregnancy and coming from low-income backgrounds 15 pregnant adolescents delivered healthy babies because of possessing positive factors such as self-efficacy, motivation to achieve career goals, and having a strong support system, which the authors referred to as a resiliency framework [ 67 ]. In Pakistan, however, the majority of women belong to patriarchal family systems, lack participation in domestic decision making, lack autonomy, and with illiteracy this leads to indecisiveness, poor self-confidence, and prenatal depression, culminating in low resilience [ 68 ].

Moreover, Payne [ 69 ] in a study conducted on teenage pregnant women outlined similarly consistent findings, indicating that individual characteristics of resilience compatible with different theoretical perspectives included, sense of purpose/meaning of life, optimism, representation of relationships, personal efficacy, self-regulation, sense of humor, self-perception, and hopefulness. To be resilient in stressful situations one must have a goal and direction that helps in restoring faith and provides a sense of meaning in life [ 70 ].

Support systems and relationships were found to be associated with resilience. Participants who had less depressive symptoms had the support of family or friends and they referred to this support as their biggest strength. A meta-analysis of 120 studies, conducted by Pilkington et al. [ 7 ] suggested that relationship satisfaction is one of the strongest protective factors against perinatal depression. On the other hand, poor communication, conflict, and dissatisfaction with the partner relationship can increase the risk of depression during the transition to parenthood [ 7 ]. The bond that pregnant women share with their spouse during pregnancy contributes to prenatal mental health and stress [ 71 ] and ensuring healthy marital relationship which is vital factor in enhancing resilience.

Another cross-sectional study conducted on 122 primiparous women also supported the notion that the main elements of resilience for reducing stress is self-confidence, optimism, positive acceptance of change, and spiritual influences [ 37 ]. Consistent results were also identified in another study where 10 pregnant women and 46 service providers were interviewed via focus groups about the personal strengths of women exposed to intimate partner violence (IPV). The results showed that increased resilience was associated with spirituality, sense of humor, and hope [ 64 ]. Faith and trust in the divine power can be a great source of motivation for those who lose hope and spirituality and resilience has been proven to be associated with each other [ 72 ]. Additionally, a prominent resilience attribute in this study was ‘Spirituality and Humanity,’ - individuals who had a strong faith in God, practiced gratitude, and were optimistic were able to cope better with stressful conditions. It was clear that humanity and spirituality were important factors in fostering and strengthening resilience among resilient participants [ 73 ].

On the other hand, Kishore [ 74 ] reported that resilience alone is not sufficient to protect women from depression during pregnancy. It should be moderated by social support particularly from friends, families, and relatives [ 74 ]. This was also identified in the current study where strengthening support systems was also found to be an attribute for enhancing resilience.

In view of the adverse impact of depression during pregnancy on the lives of women and their offspring it behooves the health care professions to develop resilience building intervention [ 75 ] which may prevent adverse mental and physical outcomes. This concept was promulgated in a study in China with 605 pregnant women which identified prenatal depression as negatively associated with resilience [ 76 ]. Hence improving women’s resilience through resilience-enhancement training can reduce the detrimental effects of pregnancy and improve women’s mental wellbeing [ 76 ]. This was also reported in a study on pregnant women in Spain, which proposed that resilience training should be introduced to improve psychological health of pregnant women and their infants [ 36 ].

The six emergent themes are well supported by closely related themes in the literature, including leading a purposeful life [ 67 , 77 ], emotional management [ 78 ], optimism [ 78 , 79 ], ,self-belief [ 77 ], positive relationships [ 64 , 79 ] and spiritual support [ 79 , 80 ].

An exploration of resilience attributes through the ecological system framework utilized in this study help researchers to conceptualize the proximal and distal factors that can predict successful development of an intervention. The literature also support the adaptation of a a multisystemic social-ecological theory to offers a perspective on intervention that focuses on variables that can be changed [ 81 ]. Hence, these six identified themes will surely aid in developing and evaluating resilience-building interventions that are culturally and contextually appropriate and can be scaled up across the country to demonstrate its ability to reduce prenatal depression. The researchers believe that it is crucial to provide perinatal women the skills which is person-centered, tailored to individual needs, and efficient in terms of both time and money. Future intervention will be designed with a focus on a highly individualized, accessible, and culturally acceptable strategies, whose advantages can be felt throughout pregnancy, parenthood, and beyond.

Strengths and limitations

Current study is the first to explore the experiences and resilience attributes of pregnant women in Pakistan. Although coming from different language and subcultural backgrounds, the sample were heterogeneous in terms of age, gestational age, education, and working status. To ensure rigor, the study used a variety of techniques. The data collection was well-organized, and interviews were done by a researcher with extensive experience in the relevant field, maintaining credibility. Additionally, the data organization and condensation processes of the data reduction and analysis steps ensured quality data where emergent themes covered the core data. To keep the confirmability, a detailed data analysis method was used, including individual researcher coding and recoding of whole datasets, followed by a group discussion of similarities and differences. Transferability was ensured by choosing participants from a variety of backgrounds to reflect the diversity of the Pakistani setting. Using purposive sampling to form a preferred sample can also assure transferability [ 82 ]. Moreover, to make the methodology reproducible by other researchers, a detailed explanation of the setting, phases of data analysis, and data gathering procedures were also provided. Trained research assistant recorded field notes and saved all raw data, observations, and reflections to maintain reliability. Furthermore, ensuring dependability, the procedure of data collecting, transcription, and analysis was finished within a predetermined time frame [ 83 , 84 ]. Moreover, we continued recruiting participants until saturation achieved in findings. This further improves the validity of the finding [ 46 , 85 ].

The limitations include firstly that the EPDS depression scores that reflect the last 15 days, might not reflect participants’ overall experiences of depression, compared to the semi-structured interview which provided a broader view of their life experiences. Secondly the study cannot be generalized to the population of Pakistan as the study only recruited a limited number of women coming from lower-socio economic backgrounds, and in keeping with research of this nature, the sampling was neither random nor representative, yet enabled rich data gathered from the small sample with the lived experience.

The six themes and attributes which emerged from the experiences of these participants provide a pathway for understanding and helping develop resilience and provide a foundation for future intervention studies. To promote mental well-being during pregnancy, in the context of a women experiencing pregnancy in a lower socioeconomic stratum in Pakistan, valid resilience building interventions that are culturally and contextually appropriate will be designed based on these findings and the language of the participants. This will not only improve the mental status of pregnant women but also their children and families.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available because the dataset contains interview transcripts, which may compromise participant privacy and confidentiality due to the sensitive nature of the topics, but are available from the corresponding author on reasonable request.

Abbreviations

Low- and middle-income countries

United Kingdom

United States of America

Aga Khan University Hospital

Edinburgh Postnatal Depression Scale

Principal Investigator

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Acknowledgements

We thank all of our participants who gave their valuable time and information. Our research team; Ms. Zara Nizar Dhamani for assisting PI in research process and note keeping during the study, Ms. Mehwish Dawood Muhammad for providing assistance in editing and formatting the references. We are also grateful to Dr. Shershah Syed and his administrators to recruit participants from his site (KGH). Ms. Kiran Shaikh and Ms. Sharifa Lakhani’s for giving access to approach their participants of CIHR study. Their team members (Naureen Akber Ali, Fouzia Karim, Rabia Khuwaja, Fazila Faisal, (also for assisting us in connecting with site administrators and for helping us. In addition, our sincere gratitude to our Maternal-infant Global Health Team (MiGHT)—Collaborators in Research members Lead Shahirose Sadrudin Premji; Members: Saher Aijaz, Naureen Akber Ali, Shahnaz Shahid Ali, Neelofur Babar, Aliyah Dosani, Christine Dunkel Schetter, Fazila Faisal, Ntonghanwah Forcheh, Farooq Ghani, Fouzia Hashmani, Nasreen Ishtiaq, Arshia Javed, Nigar Jabeen, Rabia Khoja, Sharifa Lalani, Nicole Letourneau, Heeramani Lohana, Mohamoud Merali, Ayesha Mian, Qamarunissa Muhabat, Joseph Wangira Musana, Suneeta Namdave, Christopher T. Naugler, Sidrah Nausheen, Christine Okoko, Geoffrey Omuse, Almina Pardhan, Erum Saleem, Pauline Samia, Kiran Shaikh, Nazia Shamim, Sana Asif Siddiqui, Salima Sulaiman, Afia Tariq, Sikolia Wanyonyi, Ilona S Yim.

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by university research council (grant # 182015 SONAM 70345), partial funding was also received from Canadian Queen Elizabeth Diamond Jubilee Scholarship (QES) program through University of Calgary. The current study is part of the bigger project titled “Resilience, Depression and Anxiety Among Pregnant Women In Pakistan: Development And Testing of Intervention”.

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Ethics approval was obtained from Aga Khan University Ethical Review Committee (ERC - 2020-1197-10212). Both written and oral consent were obtained from the participants by the first author who also explained the study, procedures, and risks and benefits associated with taking part in the study. Risks were minimal, however; those who were uncomfortable, uneasy, or reluctant to discuss their family life, personal issues and mental health could refuse to participate at all stages of the research. Participants were informed that all information would be treated confidentially. No monetary compensation was offered, however; counselling was offered free of cost to all individuals identified having depressive symptoms or those who required support during and following interviews. Participants were aware that there were no direct benefits by participating in the study but providing them with an opportunity to talk about intimate concerns may contribute to their mental wellbeing.

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Bhamani, S.S., Arthur, D., Van Parys, AS. et al. Resilience and prenatal mental health in Pakistan: a qualitative inquiry. BMC Pregnancy Childbirth 22 , 839 (2022). https://doi.org/10.1186/s12884-022-05176-y

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case study of depression in pakistan

Globally Minded

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Depression in Pakistan

by Onaiza Qureshi, MSc Global Mental Health candidate

Pakistan – home to approximately 182 million people of diverse races and religions who operate within limited access to healthcare, political acts of violence, and high levels of financial insecurity and social injustice. This environment is a breeding ground for mental health problems. The treatment gap for mental illness is expounded by the fact that Pakistan has a ratio of 2-3 psychiatrists per 100,000 of its population. Depression is the most prevalent mental illness and is the fourth leading cause of years lost due to disability in the country [1] , [2] . Epidemiological reports around the country put the prevalence rates of depressive and anxiety disorders between 22% and 60% with incidence varying widely between urban and rural settings [3] .

Among the many marginalized populations, the most vulnerable to depression are the females, the elderly, those from lower socio-economic groups and uneducated individuals [4] . The most dominant opinions about the causes behind depression appear to revolve around the social factors such as poverty, insecurity around terrorism and violence and population density. Moreover, factors such as marital status, interpersonal issues and financial worries were also quoted as leading to psychosocial stressors as a consequence 50 . There is also a common conception that mental disorders are caused by supernatural forces and beings such as evil Jinns (evil spirits/genie created from smoke and fire), black magic, and possession or as a punishment by God for sins committed in the past [5] (Karim et al, 2004).

There is a strong culture of stigma against depressive disorders in Pakistan. A person suffering from mental illness will yield different degrees of reaction from his community depending on the severity of the depression and its symptoms. Since depression does not manifest outward in an obvious fashion or cause visible social problems, it tends to be neglected and missed in the population when compared to more visibly noticeable disorders like schizophrenia. It may be due to this reason that many people do not seek or access help for depressive disorders in this context.

A fully functioning and up to date mental health act exists in two of the largest provinces of Pakistan; however, there is a lack of implementation for the policy to protect the rights of people with mental illnesses. Although small-scale non-governmental organizations have been doing their part in trying to change the state of mental health in Pakistan, the government itself needs to take responsibility for putting mental health on the agenda for policy, planning and implementation before any significant changes can be made.

15 / 115 is the emergency number for Pakistan.

[1] Taj, R. (2015). Mental health in Pakistan. Routledge Handbook of Psychiatry in Asia, 103.

[2] Institute for Health Metrics and Evaluation. Pakistan. Extracted from http://www.healthdata.org/pakistan

[3] Ahmed, B., Enam, S. F., Iqbal, Z., Murtaza, G., & Bashir, S. (2016). Depression and Anxiety: A Snapshot of the Situation in Pakistan. International Journal of Neuroscience and Behavioural Science 4(2): 32-36.

[4] Mirza, I., & Jenkins, R. (2004). Risk factors, prevalence, and treatment of anxiety and depressive disorders in Pakistan: systematic review. Bmj, 328(7443), 794.

[5] Karim, S., Saeed, K., Rana, M. H., Mubbashar, M. H., & Jenkins, R. (2004). Pakistan mental health country profile. International Review of Psychiatry, 16(1-2), 83-92.

© 2017 Volunteering and International Psychiatry Special Interest Group, all rights reserved. Reproduction by permission only.

case study of depression in pakistan

IMAGES

  1. (PDF) The attitudes and beliefs of Pakistani medical practitioners

    case study of depression in pakistan

  2. (PDF) PREVALENCE OF DEPRESSION AND ITS ASSOCIATED FACTORS AMONG NURSING

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  3. (PDF) Prevalence of Depression among Asthmatic Patients in Pakistan

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  4. (PDF) Stress, Anxiety, Depression, and Posttraumatic Stress Disorder

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  5. (PDF) Anxiety and Depression in Pakistani Medical Students: A Multi

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  6. (PDF) The different levels of depression and anxiety among Pakistani

    case study of depression in pakistan

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COMMENTS

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